Author ORCID Identifier

0000-0002-4112-4240

Defense Date

2024

Document Type

Thesis

Degree Name

Doctor of Philosophy

Department

Healthcare Policy & Research

First Advisor

Bassam Dahman, PhD

Abstract

This thesis presents a comprehensive examination of the impacts of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and market dynamics on the quality, billing practices, and incidence of fraud within the U.S. healthcare system. It is a compilation of three essays that each delves into a specific facet of the healthcare landscape altered by MACRA's introduction and the evolving market conditions.

Chapter 2 analyzes how MACRA has transformed Medicare Part B physicians' practices by introducing the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). The study provides empirical evidence on the shift in billing behavior and the cost implications of these changes, exploring the nuanced effects on service provision and Medicare reimbursements.

Chapter 3 explores the association between quality measures, as indicated by MIPS scores, and the incidence of fraud. It investigates whether providers engaging in fraudulent practices, identified post-2020, exhibit different patterns in MIPS performance metrics compared to non-fraudulent providers. The findings contribute to the understanding of quality in care delivery within the context of MACRA.

Chapter 4 delves into the market dynamics by assessing the relationship between health insurer market concentration and the incidence of healthcare fraud. It evaluates how the consolidation in the health insurance market might influence the prevalence of fraudulent activities, considering both the positive and negative potential outcomes of increased market concentration.

The findings from these studies offer valuable insights into how policy changes and market forces intersect to shape the healthcare landscape. The thesis suggests that while MACRA has the potential to improve healthcare quality and efficiency, its success is contingent upon careful monitoring of billing practices and the market conditions that may influence fraud. The overarching conclusion advocates for ongoing policy evaluation and adaptation to ensure that the goals of MACRA and the needs of a dynamic healthcare market are effectively balanced.

Rights

© The Author

Is Part Of

VCU University Archives

Is Part Of

VCU Theses and Dissertations

Date of Submission

2-27-2024

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